Currently Viewing:
Supplements Deaths, Dollars, and Diverted Resources: Examining the Heavy Price of the Opioid Epidemic
The Economic Burden of the Opioid Epidemic on States: The Case of Medicaid
Douglas L. Leslie, PhD; Djibril M. Ba, MPH; Edeanya Agbese, MPH; Xueyi Xing, PhD; and Guodong Liu, PhD
Estimated Costs to the Pennsylvania Criminal Justice System Resulting From the Opioid Crisis
Gary Zajac, PhD; Samaan Aveh Nur, BA; Derek A. Kreager, PhD; and Glenn Sterner, PhD
Considering the Child Welfare System Burden From Opioid Misuse: Research Priorities for Estimating Public Costs
Daniel Max Crowley, PhD; Christian M. Connell, PhD; Damon Jones, PhD; and Michael W. Donovan, MA
Currently Reading
The Opioid Epidemic, Neonatal Abstinence Syndrome, and Estimated Costs for Special Education Services
Paul L. Morgan, PhD; and Yangyang Wang, MA
Participating Faculty
Preventing the Next Crisis: Six Critical Questions About the Opioid Epidemic That Need Answers
Dennis P. Scanlon, PhD; and Christopher S. Hollenbeak, PhD
Beyond Rescue, Treatment, and Prevention: Understanding the Broader Impact of the Opioid Epidemic at the State Level
Laura Fassbender, BPH; Gwendolyn B. Zander, Esq; and Rachel L. Levine, MD
The Cost of the Opioid Epidemic, In Context
Sarah Kawasaki, MD; and Joshua M. Sharfstein, MD
The Opioid Epidemic: The Cost of Services Versus the Cost of Despair
Alonzo L. Plough, PhD, MPH

The Opioid Epidemic, Neonatal Abstinence Syndrome, and Estimated Costs for Special Education Services

Paul L. Morgan, PhD; and Yangyang Wang, MA
In 2015, a total of 2691 children were diagnosed with NAS in Pennsylvania, which translates to about 2% of recorded births.29 Approximately 80% of hospital costs for NAS, which averaged $66,693 per child in 2012 (BLS CPI: $73,262.11 in 2017 US$), are currently being charged to state Medicaid programs.14 About 20% of children with NAS subsequently receive special education services25 because of identified disabilities. A reasonable estimate of the educational costs to the Commonwealth of Pennsylvania for children with NAS who experienced prenatal opioid exposure and have identified disabilities would be more than $16.5 million (2017 US$; n = 538). The additional cost to provide special education services to children with NAS who are identified as having disabilities (ie, above the cost to provide a student with a general education) would be $8,253,458 (2017 US$) for this cohort. Table 114,25,27,29 illustrates these cost estimates.

A conservative estimate based on a limited provision of 3 to 5 years of special education services for children in Pennsylvania born with NAS would result in a lower bound estimate of additional expenses due to NAS-related disability services of $24.8 million and an upper bound estimate of $41.3 million (2017 US$). Currently, the federal government would be expected to provide approximately 15% of these special education costs28; the remaining 85% of the costs would be paid for by the Commonwealth of Pennsylvania’s local and state governments. Total costs to the Commonwealth of Pennsylvania for 3-year and 5-year time periods would amount to $21,046,318 (2017 US$) and $35,077,197 (2017 US$), respectively. These figures do not account for inflation during the 3-year and 5-year time periods.

A liberal estimate of 13-year costs of special education services (ie, kindergarten through 12th grade, assuming both early and stable disability identification and receipt of services) would amount to $91,200,711 (2017 US$), accounting for inflation each year from 2003 to 2015 (using 2017 as the reference year), as well as an 85% responsibility by the state and local governments of the Commonwealth of Pennsylvania. These cost estimates are specific to one cohort of children from Pennsylvania. Additional costs would then be entailed to provide services to both historical and future cohorts of Pennsylvania children, as well as to  those in other states diagnosed with NAS and subsequently identified as requiring additional special education services.

Estimated Special Education Costs for a Single Cohort of Pennsylvania Children With NAS Born to Mothers Using Prescription Opioids During Their Pregnancies

We also estimated a more conservative set of costs based on NAS associated with maternal prescription opioid use during pregnancy.13,30 These would be based on the following prevalence estimates: Of recorded births in the Commonwealth in 2015, an estimated 20%31 of these births were from mothers using prescription opioids (n = 27,600).30 Of the 27,600 mothers, 166 would conservatively be expected to give birth to children with NAS, using a current absolute risk rate of 6 per 1000 births. Of these 166 children with NAS born to mothers in Pennsylvania who were prescribed opioids during their pregnancies, 20% (n = 33) of these children would be expected to receive special education services because of identified disabilities. The resulting costs attributable to the additional provision of special education services for this single cohort of children are calculated as $506,253 (2017 US$) (Table 2).13,30,31 

Assuming that the Commonwealth of Pennsylvania would be responsible for 85% of costs, the estimates of 3-year and 5-year time frames are $1.3 million and  $2.2 million, respectively—that is, $1,290,945 (2017 US$) and $2,151,575 (2017 US$), respectively—to provide special education services to children born with NAS to mothers who used prescription opioids during their pregnancies. Further costs would be incurred for additional service years or additional Pennsylvania cohorts, as well as for cohorts from other states. These figures do not account for inflation during the 3-year and 5-year time periods.

If the single cohort of Pennsylvania children born with NAS from mothers who used prescription opioids received 13 years of special education services (ie, from kindergarten through 12th grade), the resulting upper bound of estimated costs would be $5,594,096 (2017 US$; Table 2).13,30,31 This estimate accounts for inflation from 2003 to 2015, using 2017 as the reference, and assumes that the state and local government would have 85% financial responsibility. Additional costs would be incurred for historical and future cohorts of Pennsylvania children, as well as for children with NAS in other states who were born to mothers using prescription opioids during their pregnancies.

Example Extension of Cost Estimates to an Additional State

These cost estimates can be applied to additional states using similar calculations. For example, an estimated 237,274 children were born in New York State in 2017.32 Using a conservatively estimated absolute risk ratio33 of 4.5 children born with NAS per every 1000 births, this would suggest that 1068 children would be diagnosed with NAS in 2015. Of this population, approximately 20% would be expected to subsequently receive special education services because of identified disabilities (n = 214). New York State currently spends an average of $22,593 per student to provide general education services, with additional special education costs resulting in $45,186 in total expenditures (Table 3).34 To provide 214 children with NAS with special education services, New York State would be expected to pay 85% of these special education costs for this single cohort, or $8,219,333 for one school year. Additional costs would be incurred for additional school years. For children with NAS born to mothers using prescription opioids during their pregnancies (20% of the number of children with NAS with special education services, or n = 43), this calculation would amount to $1,651,548 for a single school year.

Limitations and Future Directions

Few longitudinal studies have followed children born to opioid-using mothers throughout school. We extrapolated preliminary cost estimates based on this limited empirical work. These estimates may change as additional longitudinal studies become available. We did not formally search the available empirical research using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) review protocol.

Our assessments estimate the costs for children who were independently evaluated by healthcare professionals as being born with NAS. The advantage of using a diagnosis of NAS is that it more clearly establishes that the children were born to mothers who used opioids as well as other types of substances (eg, heroin), including possible prescription opioids. The negative impact of opioid use on a child’s cognitive and behavioral development can be rendered more accurately because the estimates do not rely on maternal self-reports. Maternal self-reporting might result in a less accurate history of opioid use and present an unclear picture of the impact of opioid use on a child’s neurobehavioral development. Restricting the estimates to children with NAS at birth, however, also indicates that our estimates are limited to children diagnosed with this specific condition. For example, we do not estimate the costs attributable to postnatal exposure to parental opioid use, as such estimates would likely be confounded by other factors, (eg, chaotic home environments, parental mental health, unemployment, divorce) and thus result in less reliable cost estimates. We are unable to disaggregate the costs attributable to being born with NAS that result from the neurobiological effects of opioid exposure, including through opioid agonist pharmacotherapy, from the social impacts of maternal addiction and substance misuse more generally, which pharmacotherapy is designed to manage.

Additional longitudinal studies are warranted to evaluate: prenatal exposure to opioid prescription use; NAS; children’s risk for cognitive, physical, and behavioral impairments; later disability identification; and opioid-related special education services. We were able to identify only 1 peer-reviewed longitudinal study that reported on a sample of children in the United States diagnosed with NAS, their risks for disability identification, and their receipt of special education services.25 This study was limited to estimates of disability identification risk during early childhood and analyses of a state-specific cohort. Investigations of additional longitudinal datasets would allow for more precise estimates of the extent to which children diagnosed with NAS are more likely to later receive special education services because of disabilities identified throughout their early life course. Additional studies that examine the risk for disability identification among children with NAS over time (eg, middle school and high school into adulthood), as well as investigations that report on the NAS-related risk across a wide range of specific disability conditions would also enhance the field’s currently limited knowledge. 

Author affiliations: The Pennsylvania State University (PLM; YW).
Funding: This project was supported by the Commonwealth of Pennsylvania under the project “Estimation of Societal Costs to States Due to Opioid Epidemic,” as well as by a Strategic Planning Implementation Award from the Penn State University Office of the Provost, “Integrated Data Systems Solutions for Health Equity.”
Authorship information: Concept and design (PLM); acquisition of data (PLM); analysis and interpretation of data (PLM); drafting of the manuscript (PLM; YW); critical revision of the manuscript for important intellectual content (PLM; YW); statistical analysis (PLM; YW); provision of study
materials or patients (YW).
Address correspondence:
1. Bunikowski R, Grimmer I, Heiser A, Metze B, Schäfer A, Obladen M. Neurodevelopmental outcome after prenatal exposure to opiates. Eur J Pediatr. 1998;157(9):724-730.
2. Ornoy A. The impact of intrauterine exposure versus postnatal environment in neurodevelopmental toxicity: long-term neurobehavioral studies in children at risk for developmental disorders. Toxicol Lett. 2003;140-141:171-181.
3. Nygaard E, Slinning K, Moe V, Walhovd KB. Behavior and attention problems in eight-year-old children with prenatal opiate and poly-substance exposure: a longitudinal study. PLoS One. 2016;11(6):e0158054.
4. Ornoy A, Finkel-Pekarsky V, Peles E, Adelson M, Schreiber S, Ebstein PR. ADHD risk alleles associated with opiate addiction: study of addicted parents and their children. Pediatr Res. 2016;80(2):228-236.
5. Nygaard E, Slinning K, Moe V, Walhovd KB. Cognitive function of youths born to mothers with opioid and poly-substance abuse problems during pregnancy. Child Neuropsychol. 2017;23(2):159-187.
6. Nygaard E, Moe V, Slinning K, Walhovd KB. Longitudinal cognitive development of children born to mothers with opioid and polysubstance use. Pediatr Res. 2015;78(3):330-335.
7. Wouldes TA, Woodward LJ. Maternal methadone dose during pregnancy and infant clinical outcome. Neurotoxicol Teratol. 2010;32(3):406-413.
8. Log T, Skurtveit S, Selmer R, Tverdal A, Furu K, Hartz I. The association between prescribed opioid use for mothers and children: a record-linkage study. Eur J Clin Pharmacol. 2013;69(1):111-118. 
9. Kocherlakota P. Neonatal abstinence syndrome. Pediatrics. 2014;134(2):e547-e561.
10. Hudak ML, Tan RC; Committee on Drugs; Committee on Fetus and Newborn; American Academy of Pediatrics. Neonatal drug withdrawal. Pediatrics. 2012;129(2):e540-e560.
11. Jansson LM, Velez M, Harrow C. The opioid-exposed newborn: assessment and pharmacologic management. J Opioid Manag. 2009;5(1):47-55.
12. American College of Obstetricians and Gynecologists (ACOG), Committee on Obstetric Practice; American Society of Addiction Medicine. Opioid use and opioid use disorder in pregnancy. American College of Obstetricians and Gynecologists website. Number 711; Published August 2017. Accessed June 20, 2019.
13. Desai RJ, Huybrechts KF, Hernandez-Diaz S, et al. Exposure to prescription opioid analgesics in utero and risk of neonatal abstinence syndrome: population based cohort study. BMJ. 2015;350:h2102. doi: 10.1136/bmj.h2102.
14. Patrick SW, Davis MM, Lehmann CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatol. 2015;35(8):650-655.
15. Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. JAMA. 2012;307(18):1934-1940.
16. Kozhimannil KB, Chantarat T, Ecklund AM, Henning-Smith C, Jones C. Maternal opioid use disorder and neonatal abstinence syndrome among rural US residents, 2007–2014. J Rural Health. 2019;35(1):122-132.
17. Villapiano NL, Winkelman TN, Kozhimannil KB, Davis MM, Patrick SW. Rural and urban differences in neonatal abstinence syndrome and maternal opioid use, 2004 to 2013. JAMA Pediatr. 2017;171(2):194-196.
18. Auger N, Luu TM, Healy-Profitós J, Gauthier A, Lo E, Fraser WD. Correlation of neonatal abstinence syndrome with risk of birth defects and infant morbidity. J Stud Alcohol Drugs. 2018;79(4):553-560.
19. Liu GD, Kong L, Leslie DL, Corr TE. A longitudinal healthcare use profile of children with a history of neonatal abstinence syndrome. J Pediatr. 2019;204:111-117.
20. Beckwith AM, Burke SA. Identification of early developmental deficits in infants with prenatal heroin, methadone, and other opioid exposure. Clin Pediatr (Phila). 2015;54(4):328-335.
21. McGlone L, Mactier H. Infants of opioid-dependent mothers: neurodevelopment at six months. Early Hum Dev. 2015;91(1):19-21.
22. Hunt RW, Tzioumi D, Collins E, Jeffery HE. Adverse neurodevelopmental outcome of infants exposed to opiate in-utero. Early Hum Dev. 2008;84(1):29-35.
23. Oei JL, Melhuish E, Uebel H, et al. Neonatal abstinence syndrome and high school performance. Pediatrics. 2017;139(2). pii: e20162651. doi: 10.1542/peds.2016-2651.
24. Morgan PL, Farkas G, Hillemeier MM, Maczuga S. Replicated evidence of racial and ethnic disparities in disability identification in U.S. schools. Educ Res. 2017;46(6):305-322.
25. Fill MA, Miller AM, Wilkinson RH, et al. Educational disabilities among children born with neonatal abstinence syndrome. Pediatrics. 2018;142(3). pii: e20180562. doi: 10.1542/peds.2018-0562.
26. Paulozzi LJ, Mack KA, Hockenberry JM; Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC. Vital signs: variation among States in prescribing of opioid pain relievers and benzodiazepines — United States, 2012. MMWR Morb Mortal Wkly Rep. 2014;63(26):563-568.
27. Education spending per student by state. Governing the States and Localities website. Updated June 1, 2018. Accessed June 20, 2019.
28. Griffith, M. A look at funding for students with disabilities. Education Commission of the States website. Published 2015. Accessed June 20, 2019.
29. Martin J. PHC4 data shows large increases in neonatal and maternal hospitalizations related to substance use. Pennsylvania Health Care Cost Containment Council (PHC4 ) website. Published September 27, 2016. Accessed June 20, 2019.
30. Yazdy MM, Desai RJ, Brogly SB. Prescription opioids in pregnancy and birth outcomes: a review of the literature. J Pediatr Genet. 2015;4(2):56-70.
31. Volkow ND. Opioids in pregnancy. BMJ. 2016;352:i19. doi: 10.1136/bmj.i19.
32. Henry J Kaiser Family Foundation. State health facts. Total number of births (2017).,%22sort%22:%22asc%22%7D. Accessed June 20, 2019.
33. Ko JY, Patrick SW, Tong VT, Patel R, Lind JN, Barfield WD. Incidence of neonatal abstinence
syndrome — 28 states, 1999–2013. MMWR Morb Mortal Wkly Rep. 2016;65(31):799-802.
34. Spector J. NY spends $22,593 per pupil, but there’s wide disparity. Lohud website. Published December 7, 2016. Accessed June 20, 2019.
Copyright AJMC 2006-2019 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up